FCC Medical Release Form
Each student and adult must fill out the information below completely. This form will become part of the First Christian Church's permanent file for the calendar year. This form is good for one year.
Email address *
General Information
Today's Date
Name *
Gender *
Date of Birth *
Address *
Indicate in which ministry you or your child participate *
Parent/Guardian Name *
Home Phone: *
Work Phone *
Emergency Contact *
Phone Number *
Medical Information
Insurance Carrier *
Policy Number *
Name on Insurance Card *
Primary Physician's Name *
Phone *
Comments, Medical History, Medications *
Please Read:
I hereby give permission for myself or my child to participate in an activity organized by FCC. I hereby release, hold harmless and absolve FCC, their staff, sponsors, vendors, and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively , from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event my child or I require medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the FCC staff or any adult leader acting on behalf of FCC with respect to the activity, to consent to any X-ray examination, medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information. I acknowledge these statements by checking the box below and entering in my full, legal name. *
Finally, I agree that FCC may photograph my child during their participation in the activity. I agree that FCC will be able to use them, in whole or in part, whether in original or modified form in any communication outlet, including social media. I hereby release and discharge FCC and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release. *
Never submit passwords through Google Forms.
This form was created inside of First Christian Church of Clinton, IL. Report Abuse